Background. Obesity is a chronic disease that is associated with significant morbidity and mortality, and is a national healthcare and public health concern. The prevalence of obesity is high among U.S. Veterans, with more than two-thirds being overweight or obese. The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) classify ?overweight? and ?obesity? as a body mass index (BMI) > 25 kg/m2 and > 30 kg/m2, respectively; as such, BMI assessment is an established standard of care that is supported by the Healthcare Effectiveness Data and Information Set (HEDIS) and is a CMS Physician Quality Reporting System (PQRS) cross-cutting measure. The Departments of Veterans Affairs and of Defense mandate annual universal BMI screening of Veterans for overweight and obesity. Significance. Obesity in individuals with spinal cord injury (SCI) is common due to changes in body composition, changes in energy balance, and a significant decrease in mobility. However, due to these changes, it is likely that BMI underestimates obesity and obesity-related risk in patients with SCI, compared to able-bodied individuals. Because of physical and logistical barriers to conducting height and weight assessments in Veterans with SCI, we suspect that BMI is not consistently measured in this population. Innovation. Appropriate detection and management of obesity in Veterans with SCI relies on consistent measurement of BMI and proper interpretation of BMI when it is assessed. To better understand the burden of obesity in this vulnerable Veteran population and to identify individuals at risk for obesity-related morbidity, we propose to describe system-wide variation in BMI assessment. In addition, we plan to determine the longitudinal associations between BMI and obesity-related risk in Veterans with SCI in order to determine if SCI-specific adjusted BMI risk zones are needed to properly recognize obesity and risk for comorbidity in this population. Specific Aims. Thus, our goals for this project are three-fold: 1) To characterize guideline-concordant BMI assessment in Veterans with SCI in FY16-FY18. 2) To qualitatively understand drivers of facility-level variation in BMI assessment in Veterans with SCI. 3) To evaluate and calibrate SCI-spceific, adjusted BMI-based morbidity risk zones in Veterans with SCI. As such, we will identify Veterans with SCI at risk for obesity-related morbidity whose obesity status, based on current conventional BMI risk zones, would be undetected. Methodology. We will determine facility-level annual proportions of Veterans with SCI that receive guideline-concordant BMI assessment; then identify elements that could influence implementation of BMI assessment strategies by interviewing Veterans and providers in pre-selected facilities; and finally calibrate BMI risk zones in this population by characterizing the functional form of the relationship between BMI and onset of obesity-related comorbidities. Next Steps. By identifying promising practices and key barriers to providing high quality guideline- concordant care to Veterans with SCI, this work hopes to inform practice and system organization for improved care and decreased undersirable variation. In future study, the information collected here will be used to design implementation and improvement strategies to facilitate guideline-concordant practices for Veterans with SCI throughout VHA, and especially in locations with currently low performance. Evaluating the need for adjusted BMI risk-zones specific to Veterans with SCI will allow providers to identify SCI patients who are at risk for obesity and the development of obesity-related disease, who may otherwise be undetected. Dissemination of these results throughout VHA will improve understanding of the risk of obesity and obesity-comorbidity in this vulnerable population.